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Background Peripheral ulcerative keratitis (PUK) is a severe inflammatory ocular disease that can affect patients with a long history of rheumatoid arthritis (RA). The use of biotherapy has revolutionized the treatment of the RA and has provided encouraging outcomes especially in the treatment of PUK reported in few cases. In this article, we describe the case of two patients with the history of perforated corneal ulcer complicating RA treated successfully by biologic agents. Case presentation Case 1: A 45-year-old woman was diagnosed for over 17 years with sero-positive RA refractory to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). She had received one cycle of Rituximab with clinical and biological failure. In July 2017, she presented an active RA flare with a painful left eye and a decreased visual acuity. Ocular examination revealed a corneal perforation in the left eye and a pre-perforation in the right eye. She received an emergency bolus of methylprednisolone 1 g/day during three consecutive days and was followed by Infliximab. After thirteen months, Infliximab was effective on the rheumatic disease and on the corneal involvement as it stopped its gradual perforation in the right eye, and stabilized corneal ulcer in the left eye. Case 2: A 68-year-old man had been diagnosed since 2010 with sero-positive RA refractory to csDMARDs complicated in July 2017 by corneal perforation in the right eye. He was hospitalized for his ocular involvement and his active RA. He received an emergency bolus of methylprednisolone 500 mg/day during three consecutive days and was followed by Rituximab. After six months, we observed the stabilization of the right eye corneal damage and the resolution of articular symptoms. Conclusions Our cases suggest the efficacy of Infliximab (case 1) and Rituximab (case 2) as a treatment of this severe and destructive keratolysis of the cornea complicating an active RA allowing to plan corneal graft. This positive therapeutic response will contribute to increase literature reports of this therapy success.

Abnormal puberty is often reported in children suffering from many chronic diseases. Juvenile idiopathic arthritis (JIA) is the most common joint disorder in developing children. The aim of this study was to assess sexual maturation of Moroccan children with JIA and to compare the development of secondary sexual characteristics in children with JIA to children in the general population. Forty children with JIA and 74 healthy controls were included in a cross-sectional study. The diagnosis of JIA was made according to the criteria of the International League of Association of Rheumatology. Every child was examined for the development of genitalia as per criteria given by Tanner. The children with JIA were also divided into 3 groups: pre-puberty (stage 1), puberty (stages 2-3) and post-puberty (stage 4-5), and the association between puberty and cumulative dose of steroids, disease duration, disease activity, height, weight and age was investigated. Forty children with JIA were included (22 male, 18 female); the mean of age of the patients was 11 ± 4.23 years. Puberty in the patients (mean of tanner 2.43 ± 1.36) was lower than controls (2.55 ± 1.36). The prevalence of the children in prepuberty was of 15 (37.5 %) and 8 (20 %) in postpuberty. The prevalence of the children having a delayed puberty was of 6 (15 %) versus 1(1.4 %) in healthy controls (p = 0.005). There was an association between dose of corticosteroids, age at the administration of corticosteroids and the delayed puberty in boys (p = 0.009). In addition, there was no significant association in both sex between this poor puberty and duration of JIA (p = 0.45 in boys and p = 1.99 in girls) and its activity calculated by the DAS28 (p = 0.73 in boys and p = 1). Our study suggests that the puberty is retarded in Moroccan patients with JIA comparing to healthy children and that the dose of corticosteroid and the age at its administration may contribute to delayed puberty in boys.

We aimed to assess the aspects of health-related quality of life (HRQoL) in Moroccan patients with rheumatoid arthritis (RA) and to evaluate the disease-related parameters influencing it. Two hundred fifty-five patients with RA were consecutively included. We assessed sociodemographic characteristics, cigarette smoking status, disease duration, diagnosis delay, joint pain intensity (on a 0-100-mm visual analogue scale), disease activity (by the disease activity score (DAS 28) and biological tests), structural damage (by radiographs scored using the Sharp's method as modified by Van der Heijde), functional disability (by the Health Assessment Questionnaire), extra-articular manifestations, immunological status, and treatments. The Arabic version of the Medical Outcomes Study Short Form 36 Health Survey (SF-36) was applied to assess HRQoL. All domains of SF-36 were deteriorated in a significant way comparing to the general population. The most affected subgroups of SF-36 were role limitation, role emotional, vitality, and social functioning. Women had significantly lower scores of SF-36 compared to men. Patients with decreased levels of education and low socioeconomic status had significantly lower scores of SF-36 (for all p ≤ 0.01). Current and ex-smokers had lower scores in physical domains of quality of life. Patients treated with methotrexate had better scores of mental health. Furthermore, patients receiving biologic agents had better scores of physical and social domains. Decreased scores of SF-36 were significantly correlated with disease duration, joint pain intensity, clinical and biological disease activity, functional disability, and radiographic damage. The level of antibodies against citrullinated peptides had significant correlations with the impairment of physical domains of SF-36. Physical as well as mental aspects of HRQoL in our RA patients were significantly deteriorated. Recognizing complicated relationships between HRQoL and disease-related variables among our RA patients can help to develop further management strategies to improve patients' daily living particularly with the advent of new treatments.

We aimed to evaluate the immunological status and its relationships with disease-related parameters of activity, severity and quality of life in Moroccan patients with rheumatoid arthritis (RA). Two hundred forty-five consecutive patients with RA were recruited. The following data were collected: demographic characteristics, disease duration (years), disease activity (evaluated by the disease activity score, DAS28), structural damage (evaluated by Sharp's method as modified by van der Heijde), functional disability (assessed by using the Moroccan version of the Health Assessment Questionnaire, HAQ) and quality of life (by using the Arabic version of the Medical Outcomes Study Short Form 36 Health Survey: the SF-36). Immunological status (rheumatoid factor rate, RF) and antibodies against citrullinated peptides rate (ACPAs) by the Elisa method were examined. ACPAs were detected in 75.1% of patients with a mean rate of 79.2 ± 43.8 UI. RF was detected in 80.8% of patients with a mean rate of 80.1 ± 50.6 UI. Patients with positive RF and ACPAs had higher disease activity, impaired functional ability, severe structural damage, more ocular symptoms and altered aspects of quality of life. In univariate analysis, higher levels of ACPAs were significantly correlated with the age at onset (r = 0.307), disease duration (r = 0.520), disease activity (DAS28) (r = 0.531), Sharp score (r = 0.431), and with the deterioration of all domains of SF-36 (for all p ≤ 0.01). RF levels were correlated with disease duration (r = 0.517), disease activity (r = 0.470), functional disability (r = 0.521), and the alteration of physical domains of SF-36 (for all p ≤ 0.01). In multivariate analysis, the main factors associated to ACPAs and RF levels were functional disability, structural damage and impaired QoL. Furthermore, using the SF-36 scores as dependent variables, the impairment of physical domains and the domain of vitality were significantly associated with ACPA levels while the decrease of the domain of physical function was associated with the level of RF. Our study suggests that the presence and the levels of ACPAs and RF in our RA patients are associated with more active disease, more severe joint damage, worst functional disability and altered aspects of quality of life.

We report a rare case of multifocal septic arthritis associated to spondylodiscitis and endocarditis caused by group A beta-hemolytic streptococcus (GABHS) in an immunocompetent adult, and we discuss diagnosis and therapeutic difficulties, while insisting into the rational use of corticosteroids that seems to be the only risk factor in our patient.

To determine the prevalence and predictors factors of depression in Moroccan patients with systemic sclerosis (SSc), we conducted a cross-sectional study of 59 Moroccan patients with systemic sclerosis. Patients were assessed by using the Patient Health Questionnaire depression scale "PHQ-9" and through extensive clinical histories and medical examinations. The Arabic version of HAQ and SF-36 was used to assess functional disability and health status, respectively. Forty-six patients (77.4%) presented symptoms of depression. Thirty six (61%) have a major depressive syndrome and 10 (16.4%) have a minor depressive syndrome. The PHQ-9 score was significantly higher in the patient with prolonged disease duration, severe joint pain, higher disease severity, and important acute-phase reactants. Also, depression had a negative impact on physical and mental scores. Systemic scleroderma is associated with a high prevalence of depression. Screening for depression among patients with SSc is recommended and it should be assessed for routinely.

In this study, we evaluated the relationship between enthesitis and clinical, laboratory and quality-of-life parameters in ankylosing spondylitis (AS) in Moroccan patients. Seventy-six patients were included in this cross-sectional study according to the modified New York criteria for AS. All patients had enthesitis involvement. Clinical and biological parameters were evaluated. Enthesitis were assessed by two indices: Mander Enthesis Index (MEI) and Maastricht Ankylosing Spondylitis Enthesitis Score (MASES). Disease activity was evaluated by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Functional impact was assessed by the Bath Ankylosing Spondylitis Functional Index (BASFI). The quality of life was measured by the Short form-36 (SF-36). Severity of enthesitis was significantly correlated with disease activity, functional disability and degradation of quality of life. There was no relation between enthesitis indices and disease duration or laboratory parameters. The clinical assessment of enthesitis in AS is an important outcome measure, and enthesitis indices could be used to evaluate disease activity in patients with AS.

We aimed to evaluate diagnosis delay and its impact on disease in terms of activity, functional disability, and radiographic damage in Moroccan patients with ankylosing spondylitis (AS). We recruited 100 Moroccan patients who fulfilled New York Classification criteria for AS. Diagnosis delay was defined as the interval between the first symptom of AS and the moment of a correct diagnosis. Disease activity was evaluated by the bath ankylosing spondylitis disease activity index (BASDAI), functional status by the bath ankylosing spondylitis functional index (BASFI), and radiographic damage by the bath ankylosing spondylitis radiologic index (BASRI). Measurements of spinal mobility were assessed. The average age at disease onset was 28.56 ± 10.9 years. Of the patients, 16% had juvenile-onset AS. Disease duration was 9.5 ± 6.8 years, and the average of diagnosis delay was 4.12 ± 3.99 years. There were no differences in diagnosis delay according to the age at onset, educational level, or the presence of extra-articular involvement. Our patients had altered functional ability. Patients with late diagnosis (>5 years) had statistically significant higher structural damage (BASRI) and severe limited spinal mobility. There was no correlation between diagnosis delay and the activity of disease. Few studies focused on diagnostic delay and its impact in patients with AS. It is necessary in our context to establish an early diagnosis taking into account the high frequency of severe functional disability in Moroccan AS.

The objective of this study is to develop and validate a Moroccan version of the childhood health assessment questionnaire (CHAQ), a disability measure for children suffering from juvenile idiopathic arthritis. The CHAQ has been validated in a cross-sectional study in 60 JIA, classified into systemic (33%), polyarticular (38%), extended oligoarticular (6.4%), and persistent oligoarticular (21.6%) subtypes. The CHAQ was tested for reliability and construct validity by correlating the yield of the questionnaire with other disease activity parameters. Disability index was significantly different among the four JIA subtypes. CHAQ proved to be valid in clinically discriminating between healthy subjects and patients with different patterns of JIA. The convergent validity was demonstrated by strong correlations of the disability score with the JIA score set of variables. In conclusion, the Moroccan version of the CHAQ has good psychometric properties. This validated version of the Moroccan CHAQ should help to individual follow-up of children suffering from JIA.

We report two cases of primary Non-Hodgkin's Lymphoma in the spine leading to radicular compression secondary to infiltration of lumbar body vertebras. The two patients were free of either nodular or other extra-nodular disease. Treatment consisted of chemotherapy alone, one patient have had a cauda equina syndrome and surgical decompression was performed in emergency. The patients were in remission for 20 months after diagnosis. A review is given for the incidence of primary vertebral localization of lymphoma, its diagnosis, treatment and prognosis.

This study aimed to investigate the proxy-reported Health related quality of life (HRQOL) and its determinants in patients with juvenile idiopathic arthritis (JIA). It was hypothesized that HRQOL would decrease with worsening disease and disability. Data were available in cross-sectional study on children and adolescents with JIA according to the ILAR criteria. Patient demographics, type of JIA, clinical determinants and laboratory parameters relating to JIA were obtained for each patient. Functional disability was assessed using the parent's or children's version of the child health assessment questionnaire (CHAQ). The HRQOL was evaluated using the juvenile arthritis quality of life questionnaire (JAQQ). These questionnaires were previously translated and validated in Moroccan children. A total of 80 participants were enrolled with mean age of 11 [6-17 years], and female predominance (59%). Many patients (42.5%) had oligoarticular subtype; 31.3% polyarticular subtypes and 26.2% systemic form. The mean global score of JAQQ was 2.6 +/- 1.3 (1-6). Patients with persistant oligoarticular had better gross motor function (P < 0.0001), better fine motor function (P < 0.0001), less psychosocial impact (P = 0.001), and less symptoms (P = 0.001) in comparison with polyarticular and systemic subtypes. The HRQOL assessed by the JAQQ was worse in adolescent patients in comparison with children except for symptoms (P = 0.15). The gender (P = 0.95), age at onset of JIA (P = 0.81), and evolution duration (P = 0.34) were not correlated with global score of JAQQ. The diagnosis delay was significantly associated with decrease of HRQOL (P = 0.001). The decrease of HRQOL was correlated with disease activity [pain (VAS), painful and swollen joints, erythrocyte sedimentation rate (for P < 0.0001)], with disability index (CHAQ) (P = 0.001) and presence of hip involvement (P = 0.01). This study suggests that JIA can have a significant adverse effect on the HRQOL of moroccan patients, particularly adolescents with polyarticular and systemic subtypes. Disease duration, disability score (CHAQ) and pain were the strongest determinants of poorer HRQOL.

Idiopathic avascular necrosis (AVN) of the capitate bone is an important, although rare, cause of spontaneous onset of wrist pain. Most cases involve direct or indirect trauma. Only a few reports of idiopathic avascular necrosis have been published. We present a case report of a 32-year-old woman who presented with a chief complaint of a left wrist pain, swelling and loss of all ranges of motions for approximately 1 year. She had no history of prior wrist trauma or steroid use. Laboratory testing for systemic disease or infection were negative. Diagnosis of avascular necrosis of the capitate has been made via plain film radiology, isotope bone scanning, and computed tomography scan. No etiologic factor could be identified. Surgical treatment was recommended, given drilling and autogenous bone grafting. Histological analysis showed necrotic bone. The physical therapy was implemented to restore function. Two months postoperatively, she was almost pain free.

The aim of this study is to assess the reliability and validity of the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) in Moroccan patients with knee osteoarthritis. The WOMAC was translated and back translated to and from dialectal Arabic, pre-tested and reviewed by a committee following the Guillemin criteria. The Moroccan version of the WOMAC was administered twice during a 24-48 h interval to 71 Moroccan patients with symptomatic knee osteoarthritis, fulfilling the revised criteria of the American College of Rheumatology. The test-retest reliability was assessed using intra-class correlation coefficient, and the Bland and Altman method. Internal consistency was assessed by Cronbach's alpha coefficient. Construct validity was tested by correlating the WOMAC subscales with visual analogic scale (VAS) of pain, VAS of handicap, maximum distance walked and clinical characteristics. The Moroccan version of the WOMAC showed good reliability, with ICC values of the three dimensions: pain, stiffness and physical function being 0.80, 0.77 and 0.89, respectively. Bland and Altman analysis showed that means of differences did not differ significantly from 0 and that no systematic trend was observed. Internal consistency with Cronbach's alpha for pain was found to be 0.76, and its equivalents for stiffness and physical function subscales were evaluated at 0.76, 0.90, respectively. Construct validity showed statistically significant correlation with all WOMAC subscales and VAS of pain (rho=0.38, 0.42, 0.63 respectively, P

Bone infarction refers to aseptic osteonecrosis occurring in the metaphysis and diaphysis of long bones. Hemoglobinopathies, sickle cell disease, and Gaucher’s disease are usually found. Bone infarction is rarely idiopathic. Magnetic resonance imaging has proved to be more specific to identify bone infarction. We report an exceptional case of a unique idiopathic bone infarction of distal tibia, occurring unusually in a patient with juvenile idiopathic arthritis, without major risk factors of osseous infarct, and with atypical clinical and biological abnormalities.

Adult-onset Still's disease (AOSD) is an uncommon inflammatory condition of unknown origin and pathogenesis. Pulmonary manifestations are rare and include pleuritis and transient radiological infiltrations. We report a case of a young woman with AOSD who developed unusual respiratory symptoms, with bilateral lower lobar atelectasis and restrictive syndrome and reviewed the literature on it. We illustrate the difficulties in diagnosis of atypical pulmonary defect with unusual radiological aspects and discuss causality relationship between lung abnormalities and Still's disease.

Intra-articular injections of hyaluronan are generally well tolerated; the most common adverse event associated with their use is an inflammatory reaction or a flare at the injection site. Naturally derived sodium hyaluronates have not been associated with pseudosepsis; we describe a case of severe arthritis mimicking acute septic arthritis after naturally hyaluronan. A 70-year-old woman had a medial femorotibial and patellofemoral compartment knee osteoarthritis. Hyaluronic acid injection was indicated because of the persistence of a pain while walking and restricted ability to walk 100 m, as well as the installation of a flessum. She was admitted for an evaluation of a joint effusion occurring within 48 h after the first hyaluronic acid intra-articular injection (first course), with no fever or chills. Joint fluid was found to be cloudy and contained 24,000 cells per mm(3). A knee aspiration was performed to evaluate the possibility of a joint infection. The examination of synovial fluid under phase contrast and polarizing microscopes showed no crystals, and culture on standard media was negative. Acute septic arthritis was considered to be the most likely diagnosis, and probabilistic antibiotic therapy was started. The result of the bacteriological examinations also returned negative. The absence of general signs, particularly fever and chills, with fast effusion regression in less than 4 days did not plead in favor of a septic origin. In front of this beam of arguments, antibiotic therapy was stopped after 4 days. The nonsteroidal anti-inflammatory drug (Nimésulide) was given. The clinical and laboratory test abnormalities were normalized within 2 weeks. Our case has the particularity to occur after using Curavisc, which is known as producing no allergenic reactions. Moreover, the described reaction occurred with the very first infiltration within the very first course.

Background Juvenile idiopathic arthritis (JIA) is the most common arthropathy of childhood. Different diseases affect school attendance to varying degrees. The aim of this study was to assess the impact of juvenile idiopathic arthritis (JIA) on Moroccan children’s schooling. Methods Thirty-three children with JIA were included in this study, having been previously diagnosed according to the classification criteria of the International League of Associations for Rheumatology (ILAR). Seventy-four healthy children were recruited to serve as controls. Data was obtained for all children on their school level, educational performance, and attendance. The rate of absenteeism due to health complications was noted. Results All healthy children were able to attend school (p Conclusions Our study suggested that the schooling of children with JIA was negatively impacted due to the disorder. More studies, with a larger sample of children, are needed to confirm our findings.